ARFID – Picky Eating Gone Awry

Dr. Walter Kaye and Dr. Jessie Menzel of the UCSD Eating Disorder Center Discuss ARFID and Picky Eating

Hosted by Dr. Kaye and Dr. Menzel of UCSD Eating Disorders Center
January 29, 2015

EDH: Welcome to today’s #EDHchat! We are excited to have you all with us! We would like to start by welcoming our special guests, Dr. Kaye and Dr. Menzel of UCSD Treatment Center.

Special thanks to Dr. Kaye and Dr. Menzel for helping make this event possible.

Dr. Menzel is the pediatric program manager for the UCSD ED Center for Treatment & Research. Dr. Kaye is the Director at the UCSD ED Center for Treatment and Research.

Today we will be discussing Avoidant/Restrictive Food Intake Disorder (ARFID), also known as Selective Eating Disorder (SED).

Welcome, Dr. Kay & Dr. Menzel! Happy to have you with us today! Let’s get started with some of our questions.

Please tell us a little about yourselves and your backgrounds. What are your roles at UCSD?

Dr. Kaye: I am the Director of the UCSD EDC, which is a university-based, non-profit Center of Excellence. This program serves as an international leader in research, treatment, and teaching.

I’ve trained in neurology and psychiatry and have spent my career investigating the neurobiological basis of eating disorders. This research has been translated into evidence-based treatments for eating disorders.

I have the wonderful job of leading our exceptional staff on our mission to improve the lives of sufferers and their families—both at our facilities and around the world. I am excited to be talking with ED Hope with our staff ARFID expert, Dr. Menzel.

Dr. Menzel: Thanks, Dr. Kaye. I am Dr. Menzel, the Pediatric Program Manager at the UCSD Eating Disorder Center for Treatment and Research. I earned my Ph.D. in clinical psychology from the University of South Florida and completed my internship and postdoc fellowship at UCSD.

I’ve been researching and treating eating disorders since 2003. My interests are in the development of evidence-based, innovate treatments for children and pre-teens with eating disorders.

EDH: Please tell us about the treatment that is offered at UCSD for eating disorders. What kind of eating disorders do you treat?

Dr. Kaye: At UCSD, we treat Anorexia, Bulimia, Binge Eating Disorder, ARFID, and OSFED. UCSD provides Day Treatment and Intensive Outpatient for children, adolescents, and adults in three separate clinics.

Recovery was a marathon, not a sprint. It was a relay race; I passed the baton to loved ones for support We also have one of the nation’s only inpatient combined Medical Behavioral Units specializing in eating disorders for children through young adults. Staffed with expert physicians and psychologists, our inpatient unit provides medical stabilization of abnormal cardiovascular function. As well as help those who are severely underweight and require nutritional restoration under expert care.

Lastly, we offer one-week intensive family therapy (IFT) programs for families who are transitioning between levels of care. Or are lacking evidence-based practitioners where they live or are just simply “stuck”—we’ve had families from San Diego to Shanghai.

Dr. Menzel: All of our programs utilize a combination of group therapy, family therapy, and individual therapy. We also offer nutritional support, dietetic counseling, psychiatric support, and medication management. We use a combination of evidence-based treatments throughout our programs to address our patients’ needs.

Treatments include Family-Based Treatment (the Maudsley Method), Dialectical Behavior Therapy, Parent Management Training, and Cognitive Behavior Therapy. UCSD is a leader in developing innovative new treatments for Anorexia and other eating disorders based on findings from neurobiological research.

EDH: What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

Dr. Menzel: ARFID is most often seen in kids under the age of 13. ARFID is when kids have difficulty eating. This could be a lack of interest in food, or it could be sensory aversions to food, or for some kids, they worry that something bad may happen to them if they eat. They may fear choking, throwing up, or having pain.

For kids with ARFID, difficulties with eating result in faltering growth or weight loss (pediatricians may observe that the kids fall off their growth curves). Kids also may have nutritional deficiencies or dependence on oral nutritional supplements or tube feeding.

EDH: How does ARFID differ from Anorexia?

Dr. Menzel: Unlike in Anorexia or Bulimia, the difficulties with eating are not due to concerns about body weight or shape. However, patients with ARFID are often just as medically compromised as patients presenting with Anorexia.

EDH: How could a parent determine if their child has ARFID versus picky eating?

Dr. Menzel: Picky eating is a relatively normal phenomenon in children. Many children outgrow their picky eating habits or are able to meet their nutritional needs on a picky diet. A child may have ARFID if he or she fails to gain weight or grow as expected or begins to lose weight.

Parents should also suspect ARFID if a child’s range of foods becomes severely restricted or a child has a great deal of distress or fear surrounding eating.

EDH: What evidenced-based methods are used to treat ARFID?

Dr. Menzel: Currently, there are no evidence-based methods for treating ARFID. The only research published on ARFID and picky eating treatment consist of single case studies or small case series.

Our Pediatric Clinic, for kids 13 and younger, uses evidence-based treatments for both anxiety and eating disorders. We have developed innovative age-appropriate treatments for ARFID and picky eating that we are constantly evaluating.

EDH: Does ARFID occur with any other disorders? If so, which ones?

Dr. Menzel: ARFID most commonly co-occurs with other anxiety disorders. Up to 72% of individuals diagnosed with ARFID also have a comorbid anxiety disorder.

Approximately 1/3 of patients have a related medical condition. About 13% of patients with ARFID also have an autism spectrum disorder (ASD).

EDH: What encouragement would you offer to an individual suffering with ARFID or a parent who has a child with ARFID?

Dr. Menzel: Trust your parental instincts. Many of our parents tell us that well-meaning people told them that “picky eating is normal” or that their kids “will just grow out of it.”

Parents know their children best. If you think your child’s picky eating is affecting their health or well-being, have them evaluated.

Dr. Kaye: It’s also important for parents to know that there is strong neurobiological basis for ARFID. Eating is simply more difficult for some kids.

There is also NO evidence that parents are to blame for ARFID and picky eating, or any other eating disorders. Rather parents are often best positioned to help their kids recover.

Extremely selective picky eating is NOT just a “bad habit.” Research tells us that this behavior is linked to (or embedded as part of) a child’s temperament. This means that is probably a degree of genetic and neurobiological influence driving the behavior.

EDH: What resources are available for ARFID sufferers?

Dr. Menzel: Currently, there are no great resources or information readily available for individuals suffering from ARFID. Which is why we were so excited that ED Hope invited us to talk about it.

We appreciate the support in spreading the word that ARFID is NOT anyone’s fault and that there IS help available.

EDH: What treatment protocol has UCSD used to approach ARFID? How do you empower parents to help their children overcome this disorder?

Dr. Menzel: At UCSD, we see three common ARFID presentations. Extreme selective eating, fear of vomiting or choking, and fear of eating due to gastrointestinal complaints.

For all individuals, our focus is first on returning to physical health. In this approach, we are using Family Based Therapy (Maudsley) strategies to empower parents to increase the amount of food children are eating. In order to help them gain weight and correct nutritional deficiencies.

Dr. Kaye: For children with extreme selective eating, we view their extreme eating preferences almost like a personality trait.

For these individuals, the goal is to work with the eating style – not against it – and to make the eating style as adaptable as possible. This philosophy means that we DO NOT focus on expanding the individual’s diet, but rather on getting the individual’s diet to work better for them by increasing the amount of food eaten and getting creative about filling in the nutritional holes (often using supplements or vitamins).

Dr. Menzel: Finally, because these individuals often feel embarrassed or ashamed eating in social settings, we also try to make small changes or additions to the diet. These changes are intended to help the individual be more successful eating in these situations.

For example, we’ve had kids tell us that they want to learn how to eat pizza so they can “be normal” at sleepovers. We help these kids add foods by teaching them coping skills for managing the anxiety and stress that comes along with trying something new.

We also introduce the food very gradually to make the experience less overwhelming and aversive.

For individuals with food-related fears (e.g., vomiting or choking) or individuals where gastrointestinal upset makes it difficult to eat, we turn to currently established evidenced-based treatments for anxiety disorders and pain.

Cognitive-Behavior Therapy (CBT), teaching relaxation skills and using systematic desensitization, is applied to help individuals overcome ARFID and picky eating fears related to eating.

Research also suggests that CBT can be helpful in teaching patients how to manage abdominal pain and other discomforts that might interfere with eating. Our multidisciplinary team also assists with helping patients with comorbid medical conditions manage their gastrointestinal disorders.

EDH: Thank you Dr. Kaye and Dr. Menzel for sharing this great insight and expertise about ARFID. If you or a loved one has been suffering with ARFID and picky eating, we hope this information has been helpful to you.

Increasing awareness about ARFID is important for the advancement of treatment resources and to encourage help. For more information about Dr. Kaye, Dr. Menzel, and the UCSD Eating Disorder Center visit eatingdisorders.ucsd.edu.

Thank you to everyone who participated in our Twitter chat today! Please stay tuned for future Twitter chats from EDH.

If you are in need of resources for an eating disorder, visit our website at Eating Disorder Hope.